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2006 c;�y oe ��l }� Minnesota Permit Application for Liquefied Petroleum (L.P.) Gas Installation City of Roseville Fire Prevention Bureau • 2660 Civic Center Drive •Roseville, MN 55113 Phone 651-792-7341 • FAX 651-765-1651 Date of Application Permit Number Receipt Number Application is hereby made to the Roseville Fire Prevention Bureau to: ❑ Install L.P. tank(s) — value exceeds $1, 000 ❑ Instafl L.P. gas equipment — value exceeds $1, 000 ❑ Install temporary L.P. gas equipment ❑ Other: Address Business Name Site Location Name Street Address Applicant (or Contractor) Ciry State Zip Code Phone Number Tank Capacity 9in gallons-water capacity, L.P. capacity, or pounds) Container Supports Tank Installation Protection Against Physical Damage (check all that apply): ❑ Manual Shut-Off Valve ❑ Excess Flow Valve Internal Valve ❑ Pressure Relief Valve ❑ Liquid Level Gauge Pressure Valve Distance from Tank to Property Line Distance from Tank to Building Distance from Tank to Fill Point Piping Material (steel, copper, elc.) Piping Size Piping L.P. Gas Vaporizer Type Distance from Vaporizer to Tank Distance from Vaporizer to Building L.P. Gas Installation Gas/Air Mixer Dispensing Equipment Transport Unloading/Loadin B Compressor Location Pumps Other Permit Fee Calculation 1. Fair market value of job $ 1 a. Perm it fee (based on current Building Code) $ I b. Plan check fee (.65 times permit fee in la above) $ 2. State surcharge (.0005 times value of #1, above) $ 3. Total permit fee for installation (add la, Ib and 2) $ The. undersigned agrees. to perform this job in accordance_ with the aboye information, attached-plans�nd-specifications, and the applicable provisions of the National Fire Protection Association Standard(s). Applicant Name (Please print clearly): Applicant Signature: Date: �